A nurse is caring for Mr. Johnson, who is experiencing an acute exacerbation of COPD with signs of respiratory acidosis and hypoxemia. Which of the following nursing actions is the most appropriate initial intervention to improve Mr. Johnson's respiratory status?

D) Encourage Mr. Johnson to perform pursed-lip breathing exercises.

A) Increase the supplemental oxygen delivery to 4 liters per minute via nasal cannula.

B) Position Mr. Johnson in a semi-Fowler's position to facilitate easier breathing.

C) Administer a dose of a prescribed systemic corticosteroid immediately.

D) Encourage Mr. Johnson to perform pursed-lip breathing exercises.

Mr. Johnson is experiencing an acute exacerbation of COPD with signs of respiratory acidosis and hypoxemia. Which nursing intervention is most appropriate to prioritize based on his current respiratory status?

B) Administer a bronchodilator as prescribed to reduce bronchospasm.

A) Increase supplemental oxygen to 4 liters per minute via nasal cannula.

B) Administer a bronchodilator as prescribed to reduce bronchospasm.

C) Encourage deep breathing and coughing exercises to improve alveolar ventilation.

D) Begin administration of systemic corticosteroids to reduce airway inflammation.

A nurse is caring for Mr. Johnson, who is experiencing worsening respiratory acidosis and hypoxemia despite high-flow oxygen therapy and frequent bronchodilators. Considering his condition, what is the most appropriate nursing intervention to implement next?

B) Initiate non-invasive positive pressure ventilation (NIPPV)

A) Increase the frequency of bronchodilator administration

B) Initiate non-invasive positive pressure ventilation (NIPPV)

C) Provide supplemental oxygen via nasal cannula

D) Administer a sedative to reduce anxiety and improve breathing

A nurse is caring for Mr. Johnson, who has been diagnosed with worsening respiratory acidosis and hypoxemia. Which intervention should the nurse anticipate to improve Mr. Johnson's alveolar ventilation and reduce his work of breathing?

B) Start non-invasive positive pressure ventilation (NIPPV)

A) Initiate low-flow nasal cannula oxygen therapy

B) Start non-invasive positive pressure ventilation (NIPPV)

C) Administer a higher dose of bronchodilators

D) Prepare for intubation and mechanical ventilation

A nurse is caring for Mr. Johnson, who is experiencing worsening cor pulmonale and peripheral edema despite current interventions. Which nursing action is most appropriate to prioritize at this time?

B) Elevate the head of the bed to 45 degrees to improve respiratory effort.

A) Increase the frequency of diuretic administration to manage fluid overload.

B) Elevate the head of the bed to 45 degrees to improve respiratory effort.

C) Notify the healthcare provider to reassess the need for pulmonary vasodilators.

D) Initiate continuous cardiac monitoring to detect arrhythmias early.

A nurse is caring for Mr. Johnson, who has been diagnosed with pulmonary hypertension secondary to chronic obstructive pulmonary disease and is showing signs of cor pulmonale. Considering his current condition, which nursing intervention should be prioritized to prevent further deterioration?

C) Monitor daily weight and intake & output to assess fluid status

A) Increase the oxygen flow rate to maintain oxygen saturation above 95%

B) Administer a high-sodium diet to improve cardiac output

C) Monitor daily weight and intake & output to assess fluid status

D) Encourage Mr. Johnson to ambulate frequently to prevent venous stasis

Mr. Johnson's current clinical presentation includes persistent peripheral edema, worsening jugular venous distension, increased respiratory rate, and decreased oxygen saturation despite current treatment. Which of the following nursing interventions is most appropriate to address these changes?

C) Adjust the inspiratory pressure support on the NIPPV to enhance ventilation.

A) Increase the FiO2 on the NIPPV to improve oxygen saturation.

B) Administer a bolus of intravenous fluids to improve cardiac output.

C) Adjust the inspiratory pressure support on the NIPPV to enhance ventilation.

D) Withhold diuretics to prevent further electrolyte imbalance.

A nurse is caring for Mr. Johnson, who is experiencing worsening respiratory and cardiac symptoms despite current interventions. Which intervention should the nurse prioritize to address Mr. Johnson's impaired gas exchange and fluid overload?

A) Increase the inspiratory pressure support on the NIPPV to enhance ventilation.

B) Administer an additional dose of diuretics to reduce peripheral edema.

C) Initiate continuous renal replacement therapy to manage fluid overload.

D) Administer supplemental oxygen via nasal cannula at 4 L/min.

A nurse is caring for Mr. Johnson, who has been diagnosed with cor pulmonale secondary to COPD. His treatment plan includes a combination of loop and potassium-sparing diuretics, increased inspiratory pressure support on NIPPV, and supplemental oxygen titration. Which nursing action is most important to monitor for potential complications from this treatment plan?

B) Assess for signs of respiratory acidosis

A) Monitor for signs of hypokalemia

B) Assess for signs of respiratory acidosis

C) Evaluate for symptoms of fluid overload

D) Check for signs of oxygen toxicity

Considering Mr. Johnson's current treatment plan and response, which nursing intervention should take priority to further optimize his respiratory status?

B) Monitor and adjust the settings of the NIPPV to ensure adequate ventilation.

A) Encourage Mr. Johnson to perform incentive spirometry every hour.

B) Monitor and adjust the settings of the NIPPV to ensure adequate ventilation.

C) Administer a bronchodilator nebulizer treatment every 4 hours as prescribed.

D) Increase Mr. Johnson's fluid intake to promote renal clearance of CO2.

COPD - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic inflammation leads to structural changes in the airways, resulting in narrowing and obstruction. This ongoing inflammation is triggered by inhaled irritants like cigarette smoke and pollutants, causing damage to lung tissue and impaired airflow.

• Secondary mechanism: Loss of elastic recoil in the alveoli due to degradation of elastin fibers, primarily caused by an imbalance between proteases and antiproteases. This results in air trapping and hyperinflation, further contributing to airflow limitation and increased work of breathing.

• Key complication: Persistent airflow obstruction and lung tissue damage lead to reduced oxygen exchange, causing hypoxemia and hypercapnia. Over time, this can result in pulmonary hypertension and right-sided heart failure (cor pulmonale), significantly impacting patient quality of life and increasing morbidity.

Patient Profile

Demographics:

65, male, retired construction worker

History:

• Key past medical history: 10-year history of COPD, hypertension, former smoker (40 pack-years)

• Current medications: Tiotropium, Albuterol inhaler, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing shortness of breath and productive cough

• Key symptoms: Wheezing, fatigue, occasional chest pain, increased sputum production

• Vital signs: Blood pressure 150/95 mmHg, heart rate 105 bpm, respiratory rate 24 breaths/min, oxygen saturation 88% on room air, temperature 99.1°F

Section 1

As the patient, Mr. Johnson, continues to be monitored in the clinic, his respiratory status begins to show signs of deterioration. Despite being on supplemental oxygen at 2 liters per minute via nasal cannula, his oxygen saturation remains borderline at 90%. Auscultation of the lungs reveals diffuse wheezing and decreased breath sounds in the lower lobes, suggesting possible airway obstruction and areas of atelectasis. There is increased use of accessory muscles and a pursed-lip breathing pattern, indicating increased work of breathing. The nurse notes that Mr. Johnson is increasingly fatigued and has difficulty speaking full sentences without pausing to catch his breath.

Recent arterial blood gas (ABG) analysis reveals a pH of 7.32, PaCO2 of 55 mmHg, and PaO2 of 68 mmHg, indicating respiratory acidosis with hypoxemia. These findings suggest that Mr. Johnson is experiencing an acute exacerbation of COPD, potentially due to an infection or environmental irritant, exacerbating his chronic condition. The elevated PaCO2 and decreased pH point towards hypercapnia, a consequence of inadequate ventilation and gas exchange. Given his history and current presentation, further diagnostic testing, including a complete blood count and sputum culture, is warranted to evaluate for possible infection and guide antibiotic therapy, taking care to avoid penicillin due to his known allergy.

The healthcare team is concerned about the risk of progression to acute respiratory failure if Mr. Johnson's condition does not stabilize. They initiate a high-flow oxygen therapy and administer bronchodilators more frequently to relieve bronchospasm and improve ventilation. The team also considers the start of systemic corticosteroids to reduce airway inflammation. Mr. Johnson's healthcare providers emphasize the importance of monitoring his cardiac status closely, as the increased strain on the heart could precipitate cor pulmonale, a known complication in patients with advanced COPD. The next steps in Mr. Johnson’s management will depend heavily on his response to these interventions and the results of the pending diagnostic tests.

Section 2

Change in patient status:

Despite the initiation of high-flow oxygen therapy and more frequent administration of bronchodilators, Mr. Johnson's condition shows only minimal improvement. His oxygen saturation remains precariously low, hovering around 88-89%, and he continues to struggle with significant dyspnea. The nurse observes that Mr. Johnson is becoming increasingly lethargic and less responsive, raising concerns about worsening hypercapnia and potential carbon dioxide narcosis. His vital signs reveal a blood pressure of 145/90 mmHg, a heart rate of 110 beats per minute, and a respiratory rate of 28 breaths per minute, all of which indicate heightened physiological stress.

Given these concerning signs, the healthcare team decides to repeat the arterial blood gas analysis. The results show a further decline in his respiratory status, with a pH of 7.28, PaCO2 of 60 mmHg, and PaO2 of 65 mmHg, confirming worsening respiratory acidosis and hypoxemia. These findings indicate that Mr. Johnson's current ventilation strategy is insufficient, and there is a pressing need to escalate care. The team considers the initiation of non-invasive positive pressure ventilation (NIPPV) to enhance alveolar ventilation and reduce the burden of work on his respiratory muscles.

As Mr. Johnson's condition evolves, the healthcare team remains vigilant for signs of cor pulmonale, particularly given his tachycardia and elevated blood pressure, which could reflect increased pulmonary artery pressures. The decision to initiate systemic corticosteroids is reinforced by the need to address the underlying inflammation contributing to his respiratory compromise. The team plans to reassess Mr. Johnson regularly, emphasizing the importance of monitoring his mental status, cardiac function, and respiratory parameters to guide further interventions and prevent progression to acute respiratory failure.

Section 3

After initiating non-invasive positive pressure ventilation (NIPPV), Mr. Johnson's initial response is cautiously optimistic. His respiratory rate decreases to 24 breaths per minute, and his oxygen saturation improves slightly to 91%. However, the healthcare team remains concerned about his persistent lethargy and begins a thorough neurological assessment to rule out further complications. They note that Mr. Johnson is difficult to rouse and responds only to painful stimuli, suggesting a deepening level of sedation potentially due to hypercapnia. The team revisits his medication regimen, ensuring that no other sedatives are contributing to his decreased responsiveness.

As part of the ongoing assessment, Mr. Johnson's cardiovascular status is closely monitored for signs of cor pulmonale or right-sided heart failure. An echocardiogram is performed, revealing mild right ventricular hypertrophy and elevated pulmonary artery pressures, consistent with pulmonary hypertension secondary to chronic obstructive pulmonary disease. This finding corroborates the clinical suspicion that his heart is under strain due to the respiratory compromise. With these results, the team considers starting a low-dose diuretic to manage potential fluid overload and reduce cardiac stress, while keeping a close watch on Mr. Johnson's renal function and electrolyte balance.

Despite the interventions, Mr. Johnson develops a new complication: increasing peripheral edema and jugular venous distension, indicating worsening cor pulmonale. This prompts the team to adjust his management plan, incorporating more aggressive measures to optimize his respiratory status and cardiac output. They initiate a pulmonary vasodilator to alleviate pulmonary hypertension while maintaining NIPPV to support ventilation effectively. The team continues to monitor Mr. Johnson's progress, ready to escalate care if his condition does not stabilize. This integrated approach highlights the importance of addressing both respiratory and cardiac aspects of his condition, aiming to prevent further deterioration and improve his overall prognosis.

Section 4

As the team continues to manage Mr. Johnson's condition, they observe a change in his status that necessitates immediate attention. Despite the initiation of a pulmonary vasodilator, Mr. Johnson's peripheral edema persists, and his jugular venous distension worsens. His respiratory rate, although initially improved, begins to increase again, rising to 30 breaths per minute, and his oxygen saturation dips to 88% on the current NIPPV settings. These changes suggest that his respiratory and cardiac functions are not yet optimally balanced, prompting the team to reassess their approach.

In addition to these clinical signs, a follow-up arterial blood gas analysis reveals worsening hypercapnia, with a pCO2 level of 68 mmHg, up from 62 mmHg previously. His pH remains stable at 7.34, indicating that his body is attempting to compensate for the respiratory acidosis but is under considerable strain. The findings suggest that despite non-invasive ventilation, Mr. Johnson's alveolar ventilation is insufficient, potentially due to fatigue or worsening obstruction. The healthcare team considers adjusting the NIPPV settings to increase inspiratory pressure support, thereby enhancing ventilation and reducing CO2 retention.

Simultaneously, they review Mr. Johnson's fluid status more critically, given the persistent edema. Serum electrolytes indicate mild hyponatremia and hypokalemia, likely related to diuretic therapy, necessitating careful re-evaluation of his diuretic regimen to avoid exacerbating electrolyte imbalances. Balancing the fluid management while optimizing ventilation becomes a crucial focus, as these intertwined aspects of care are vital to stabilizing Mr. Johnson's condition. This situation underscores the need for vigilant monitoring and a dynamic treatment approach, integrating respiratory and cardiovascular support to improve his clinical trajectory.

Section 5

As the team delves deeper into Mr. Johnson's condition, they decide to focus on his fluid status, given the persistent peripheral edema and worsening jugular venous distension. A repeat echocardiogram is conducted to assess his cardiac function more accurately. The results reveal mild right ventricular hypertrophy and elevated pulmonary artery pressures, consistent with cor pulmonale secondary to his long-standing COPD. This finding confirms that his heart is struggling to cope with the increased workload imposed by his compromised lung function, contributing to his worsening fluid retention.

In response to these diagnostic insights, the healthcare team decides to adjust Mr. Johnson's treatment plan. They carefully modify his diuretic therapy, opting for a combination of loop and potassium-sparing diuretics to manage the edema while minimizing the risk of further electrolyte imbalance. Concurrently, they increase his inspiratory pressure support on the NIPPV, aiming to enhance alveolar ventilation and help reduce CO2 retention. They also initiate supplemental oxygen titration, cautiously balancing to avoid further hypercapnia, as they seek to maintain his oxygen saturation above 90%.

Over the next 24 hours, the team observes Mr. Johnson's response to the revised interventions. His respiratory rate begins to stabilize, decreasing to 26 breaths per minute, and his oxygen saturation improves slightly to 90%. Repeat arterial blood gas analysis shows a modest reduction in pCO2 to 65 mmHg, indicating some improvement in his ventilation. However, Mr. Johnson still exhibits significant fatigue, and the team remains vigilant, recognizing that his condition requires close monitoring and potential further adjustments. The focus is now on fine-tuning the therapeutic balance to ensure he progresses towards a more stable state, setting the stage for the next phase of his management.